Residency guides the transformation of medical student to independent practitioner. It requires longitudinally-concentrated effort on the part of the resident whose essential learning activity is interaction with patients under the guidance and supervision of faculty members. As experience is gained and growth demonstrated, roles are assumed that permit the exercise of skills with greater independence. This concept - graded and progressive responsibility - is a tenent of the Accreditation Council for Graduate Medical Education (ACGME). The ACGME "Milestones" are used as a tool to ensure residents are able to practice core professional activities upon graduation. Residents who have not satisfied the Program's requirements for advancement to indirect supervision as defined by the ACGME will not undertake any patient activity leading to change of status, acuity, or management, without the physical presence of an appropriately qualified physician. However, residents will not interpret this in such fashion to curtail legitimate learning. All residents are encouraged to carry out whatever activities are necessary to strengthen history taking and physical examination skills, together with improving rapport with patients and their families, with whatever frequency the resident deems necessary. In the maturation of those skills, there is no substitute for patient contact.